Every finding on record at Alden Estates of Skokie

Based on interview and record review, the facility failed to maintain documentation of education and offering Covid-19 vaccination to staff, and failed to follow facility Covid Vaccination Policy regarding education of Covid vaccine. This has the potential to affect all residents in the facility. Findings include: On 10/22/24 at 1:20 PM, V2 (Director of Nursing (DON)/ (IP) Infection Preventionist) stated, We do offer Covid vaccinations for staff and residents yearly. Most of the time staff goes to local pharmacies to get theirs. Most of them do not take vaccination when we offer it. I have a flu/covid clinic scheduled for next week for staff and residents. On 10/22/24 at 1:54 PM, V8, Licensed Practical Nurse (LPN), stated, 'I refused the Covid vaccination last year. The last one I received was in 2022. I did not sign a declination. On 10/22/24 at 1:55 PM, V2 stated, We offer Covid and Flu vaccines to staff but we do not keep record of refusals or education. Most of staff go to local pharmacies if they want the vaccine. On 10/23/24 at 10:09 AM, V9 (Social Worker) stated, We are offered Covid and flu shots each year. I do not remember if we have to sign anything. They do an in-service on flu and Covid. On 10/23/24 at 10:19 AM, V5, Certified Nursing Assistant (CNA), stated, I submitted my documentation for flu and Covid vaccinations before I started. They have not offered or given me education on Covid 19 yet. I do not know if they offer it. On 10/23/24 at 10:22 AM, V6, CNA, stated, In the beginning of Covid they offered Covid and flu. They offer flu immunization each year. The last time they offered Covid was about last year or year before. They educate us on both by in-service. I got all the Covid shots, so I signed a consent. If we declined, we had to sign a refusal. I have not receive any education this year or offered Covid 19 vaccine this year. On 10/23/24 at 10:26 AM, V3 (Business Office Manager) stated, We are offered Covid and flu shots each year. We do not have to sign a refusal for Covid, but we do sign a declination for flu if we do not want it. We can also get immunizations from outside sources, we just have to provide proof for our records. On 10/23/24 at 9:53 AM, V7 (Licensed Practical Nurse/LPN) stated, We are offered flu and Covid shots through facility and we have to sign a consent or refusal, but I am new in this building. I have not signed any refusals or consents for flu or Covid here at this building yet or receive any education for Covid-19 or flu. On 10/23/24 at 10:37 AM, V2 stated, So, every time there is a new Covid booster out, when staff picks up their checks, we talk about vaccine and the staff will say sign me up. If there is no new booster out, we still talk about it, but it is their choice. We talk about what is available to them. We do encourage them to take the Covid vaccine. The memo is just telling them where they can go get it. People from outside must come here to do it. The outside vendors will do staff vaccinations as well. (V3, Human Resource) will post something by the time clock and those who want the vaccine will put their name down. For flu, we do have declinations, but for Covid they do not have to sign a declination. At the beginning of Covid, they did have to sign a refusal. I do not remember when having the declination signed by the staff stopped for Covid. I usually talk about how they can get flu and Covid vaccines, and when to get it, and when to stay home as education. I can look through my binder to see if I have sign in sheets for in-services for the education part of that. On 10/23/24 at 11:32 AM, V2 provided Covid policy and stated, We do educate them if they have any symptoms and should not come to work. We do not screen employees for Covid. We do not any longer get signed declinations for Covid vaccine, but we encourage all staff to get the Covid vaccines yearly when we do the flu vaccine, or a new booster comes out. I do not have any declinations for Covid vaccine. The in-services I provided to you are the only education we offer regarding the Covid vaccine. Vaccination status is documented by getting a copy of their vaccination cards and keep copy in the binder for Covid vaccines. If staff get another vaccine, they provide us with a copy of new card/vaccine documentation for binder. On 10/23/24 at 1:56 PM, V2 was asked for documentation for screening for Covid vaccinations. V2 stated No, we do not have anything like that. We do not screen for Covid vaccine. On 10/23/24 at 2:25 PM, V2, DON/IP, provided surveyor with a report listing employees and Covid vaccination dates, but complete documentation omitted for V10 (New Staff) and V11 (Staff) and V12 (Staff) with religious exemption. Surveyor asked V2 if that was all the documentation that she had regarding Covid vaccine education, screening, and offering vaccines to employees. V2 stated, Yes the in-services I provided to you is all I have. V2 provided surveyor Covid 19 documents posted by the time clock and Memo date 01/01/2024 to all Skokie Staff stating, This is a reminder to get your COVID vaccine/boosters. Please scan below QR codes for information on the vaccines. You can easily receive your COVID vaccine/booster at your local pharmacy or at your primary care provider. If you do receive the vaccine, please bring a copy of your vaccine card to (V3, Business Office Manager). This memo had education pages that did not document risks/benefits of vaccine attached to memo, but had QR codes that goes to link with risk/benefits of each Pfizer and Moderna covid vaccines. V2 could not provide a list of staff that received this memo. In-service document provided and dated as follows (in part): Date: 7/12/23, Topic: Covid Guidance Updates, summarize what you discussed: New Hospital Admission Rate Date: 1/5/24 Topic: Covid Policy Discussed: The facility will manage residents with confirmed or suspected Covid-19 infection in accordance with recommendations from the CDC, state and local health department. Date: 1/29/24 and 11/29/24 Topic: Covid-19 Symptomatic Discussed: Should individual with symptom consistent of Covid-19 have negative results from a rapid antigen test, they should remain excluded from work and/or isolated pending results of confirmatory PCR testing. Date: 1/26/24 Topic: Covid-19 Discussed: All staff members to put N96 masks on each time going to patients rooms. Proper PPR donning and doffing needs to be done Must take vitals every 4 fours. Door kept close at all times. During the course of the survey, the facility did not provide requested Covid-19 declination forms to surveyors nor staff education in-services for current 2024 (fall season) Covid-19 vaccine. The facility's policy, dated 07/2023, Covid-19 Vaccination Policy stated (in part): Policy Vaccination remains critically important in reducing risk of hospitalization and death due to Covid-19. The facility will encourage staff to remain up to date with Covid-19 vaccination, including all eligible booster doses. Education 1. The facility will provide education to all staff and residents regarding the COVID-19 vaccine they are offered, in a manner they can understand, including information on the benefits and risks consistent with the CDC (Centers for Disease Control and Prevention) and/or FDA (Food and Drug Administration) information. This education will at a minimum include the FDA EUA (Emergency Use Authorization) Fact Sheet or Vaccine Information Sheet for the vaccine(s) being administered.

Based on interview and record review, the facility failed to develop and evaluate an individualize plan to include supervision and monitoring to reduce the risk for falls for a resident with a dementia and poor safety awareness. This affected one of three (R1) residents reviewed for safety and fall prevention. This failure resulted in R1 having an unwitnessed fall being sent to the local hospital and treated for left femur fracture. Findings include: R1 face sheet shows diagnosis of vascular dementia, fracture of femur neck, muscle weakness, difficulty walking, abnormalities of gait and mobility, Parkinson disease, and history of falling. R1 fall risk evaluation assessment, dated 2/17/24, denotes a score of 8, risk factors are decreased mobility, confused, one to two falls in past three months, R1 takes medication that have a diuretics effect or increase GI (gastrointestinal) mobility, drugs that affects the thought process, drugs that create a hypotensive effect, R1 is regularly incontinent, needs assist to get to the toilet. R1's Minimum Data Set/MDS, dated [DATE] section C, shows BIMS (Brief Interview for Mental Status) score of 14 (cognitively intact), when asked the day of week, R1 coded for 0 (incorrect answer). Section GG for functional abilities and goals denotes on admission R1 walked 10 feet with supervision or touching assistance, toilet transfer denotes 04 (supervision or touching assistance), Section J denotes yes for falls within the last month prior to admission and yes for fractures related to fall in the 6 months prior to admission, yes for falls since admission, 1 is coded for major injury. Facility final incident report to the department denotes R1's name, R1's date of birth, date of admission, R1's diagnoses- included but limited to chronic obstructive pulmonary disease, hemiplegia and hemiparesis and affecting right dominant side, vascular dementia, parkinson disease. R1 is a [AGE] year-old male, alert and orient x2, forgetful, able to make needs known to staff. R1 is in the facility for short term rehab status post fall at home. Description of occurrence on February 22nd, 2024 staff noted (R1) lying on the floor on his right-side. (R1) was transferred to hospital for evaluation and admitted for a diagnosis of overriding fracture of the femoral shaft. MD (medical doctor) and family made aware investigation initiated. Investigation completed interviews and record reviews were conducted (R1) is [AGE] year-old male admitted to the facility on [DATE] for physical therapy and occupational therapy for diagnosis noted above. (R1) is ambulatory using a walker with a slow steady gait. On February 22, 2024, around breakfast time (R1) was eating breakfast in his bed as his usual routine with call light within reach. (R1) voice nothing else was needed before staff left the room and was reminded to use the call light for staff assistance. The housekeeper went into the residence room to complete daily cleaning and observed resident lying on the floor. Nurse on duty was immediately notified. Per resident he needed to go to the bathroom but did not call for staff assistance. When asked why he didn't call for assistance resident didn't answer and just shrugged his shoulders. Per staff interviews resident routinely called for staff assistance when needed by activation of call light. Residents score 14 on the BIMS (Brief Interview Mental Status) and had no prior incidents or accidents in the facility. On 2/17/2024, 2/18/2024 and 2/21/2024, resident was educated on safety precautions and to not get up without staff assistance and to use call light. Upon resident return care plan will be reviewed and updated accordingly. R1 emergency room records, dated 2/22/2,4 shows diagnosis of fracture of left femur. Chief complaint, paperwork lists vascular dementia as a diagnosis, but he is able to give history appropriately. States he was walking with his walker, and the wheels of the walker locked up, and he fell forward/ tripped. Has pain and deformity of the L (left) hip, cannot stand or move the leg too well. No head or neck injury. Tore the skin of the L (left) arm, but has normal function, normal ROM (range of motion). No weakness. No new numbness. No neck pains. Physical exam left leg shortened and internally rotated at the hip. New left femur shaft fracture, discussed with hospitalist, will need further surgery. R1 root cause analysis for fall on 2/22/2024 denotes, on February 22, 2024, (R1) was going to the bathroom without calling for assistance. Based on the investigation the factor that contributed to his fall was right sided weakness. He stated he fell on his left side but was observed by staff on the floor on his right side. R1 progress notes, dated 2/22/24 at 8:20am, denotes, A staff member called for author's attention this morning because the staff member was passing patient's room when they saw that the patient was on the floor. Author immediately went to patient's room; patient's call light was not on. Author assessed the patient, and he is noted to be on his right side in front of the doorway. Author asked patient to describe what happen, but patient unable to give a clear story as the patient is forgetful at baseline. Patient is alert and responsive. Patient states he was walking on his own with the walker to use the bathroom when he lost his balance, patient states he did not call for any help or use his call light. Patient is currently on his right side, but patient able to recall that he fell on to his left side. Noted 2 skin tears with bleeding to the left arm. Redness is noted on patient's head, but patient states he did not hit his head. Patient neuro is intact, able to answer questions, upper extremities are strong. Patient has pain to his left leg and is unable to straighten his leg on his own at this time. Nursing staff is present with the patient and did not move patient, placed pillow behind patient's head to make him comfortable. Called 911 due to patient being on blood thinners and pain to left surgical leg for evaluation. Doctor made aware with orders to send out to (city) ER (emergency room ) for evaluation. Left arm skin tears cleansed with NSS( normal saline) and covered with dressing. Patient was transferred to (city) ER with 911. Patient's wife (name) made aware and is amenable. Doctor (orthopedic surgeon) office called, and PA (physician assistant) made aware and will alert Doctor that patient is at the hospital. Facility employee interviews denotes V6 (Unit Manger) coming from front walking to a nursing station nurse on duty asked me to help ( room number) when I walked in patient was noted laying on the floor on his right side with his left arm bleeding his walker was next to him call light was not on. (V4) and (V7) asked him what happened patient stated he was trying to go to bathroom by himself. Paramedics arrived and assisted him on the stretcher two of the paramedics lifted him by his arms and did not support his legs as they were transferring him patient was then taken to hospital. On 5/4/24 at 9:11am, V1 (R1's family) said R1 was admitted to the facility after a fall at home where he sustained a left hip fracture requiring surgery. V1 said R1 fell at home while going to the bathroom. V1 said she received a call for the facility on 2/22/24, and she was informed R1 was observed on the floor, and that he will be sent to the hospital for evaluation. V1 said R1 was diagnosed with a left femur fracture and required surgery. V1 said R1 told her he fell while going to the bathroom. V1 said she doesn't remember if R1 said he put his call light on prior to taking himself to the bathroom. V1 said R1 does need help going to the bathroom. V1 said she informed the facility R1 fell at home, and the facility was aware that R1 was a fall risk. On 5/4/24 at 11:06am, V2 (Nurse) said he was notified R1 was on the floor, he went to assess R1, R1 observed on his right side but R1 was able to communicate that he fell on his left side. V1 said R1 was not moved, and 911 was summoned to escort R1 to the hospital for evaluation. V1 said the physician and surgeon were made aware and the physician gave orders for R1. V1 said he doesn't recall where R1's walker was at that time. On 5/4/24 at 2:31pm, V3 (Director of Nursing) said R1 had an unwitnessed fall sustaining a fracture. V3 said her investigation concluded R1 got up to go to the bathroom without assistance from staff. V3 said R1 has right side weakness and he fell . V3 said she doesn't know if R1 had on shoes, she doesn't know if R1 had on skid free socks, she doesn't know if R1 tripped over something, she doesn't know if R1's urinal was available to him, she doesn't know if it was full and not able to be used. V3 said R1 was usually complaint with using the call light for assistance to the bathroom. V3 said she doesn't know what was different on that day. V3 said the facility keeps all the residents roller walkers at the bedside. V3 said it is better the resident be able to reach the walker than fall trying to reach the walker. V3 said R1 call light was within reach, attached to the side half rail. V3 said she is aware R1 had a fall at home, but she doesn't know the situation surrounding the fall. V3 said R1 has dementia. V3 said she would have to find out if R1 has poor safety awareness. V3 said she conducted the fall investigation for R1. V3 was asked, How is the facility reducing the risk for falls when the roller walker is left at the bedside for the resident to reach and use at liberty? V3 did not respond. On 5/4/24 at 2:40pm, V4 (Rehab Director) said he did not complete R1's physical therapy evaluation, but was agreeable to review the evaluation. V4 said, (R1) was referred to therapy, (R1) was evaluated, and (R1) ambulates with minimal assist meaning support of 25% is needed. Support can be provided with use of gait belt, and someone is physically there. (R1) needed support because (R1) was a fall risk, he had forward lean, he wobbled and had a weak pelvis. V3 said R1 should not be ambulating by himself. V3 said R1 had poor safety awareness, needed verbal cueing during walking. with ambulation. V4 said, The walker should not be left at the bed side because you don't want to promote the resident to use the walker. It can stay in the room but away from the resident. Facility policy titled care plans, dated 8/2020, denotes management of falls the facility will assess hazards and risk develop a plan of care to address hazards and risk, implement appropriate resident interventions, and revise the resident plan of care in order to minimize the risk for fall incidents and or injuries to the resident. Develop a plan of care to include goals and interventions which addresses residence risk factors. Risk factors may include but are not limited to the following contributing diagnosis disorders disease processes active infections other comorbidities history of fall incidents incontinence medications assistance required with ADL's gate transfer balance issue behaviors and or cognitive status. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards.

Based on observation, interview, and record review, the facility failed to account for the receipt of the controlled medication for one of eight residents (R10) reviewed for controlled medications in a sample of 12. Findings include: On 02/08/2024 at 11:33AM during observation with V7 (Licensed Practical Nurse/LPN) of the south medication cart, R127's Controlled Drug Receipt/Record/Disposition Form did not indicate the signature of nurse receiving medication, quantity received, or date of receipt. On 02/08/2024 at 11:35AM, V7 said R127's Controlled Drug Receipt/Record/Disposition Form should indicate the signature of nurse receiving medication, quantity received, and date of receipt. On 02/09/2024 at 10:50AM, V2 (Director of Nursing) stated the nurse receiving the controlled medication is expected to verify the quantity received, sign, and date the Controlled Drug Receipt/Record/Disposition Form. Review of facility's policy entitled Controlled Drug Documentation, dated 06/2022, indicated: A. Purpose: To maintain control and prevent loss and/or diversion of controlled substances. C. Procedure: 1. For each controlled substance dispensed individually, pharmacy supplies a pink proof-of-use form (Controlled Drug Receipt/Record/Disposition Form), pre-printed with resident and medication information. a. The nurse receiving the medication delivery will indicate on the quantity received and sign/date the accompanying proof-of-use form;

Based on interview and record review, the facility failed to implement effective fall interventions and provide adequate supervision to one resident (R1) out of four residents (R1, R2, R3, and R4) who were reviewed for falls. This failure resulted in R1 experiencing three falls in less than one month, and one of these falls resulting in a fractured right clavicle. R1 is a [AGE] year old male who was originally admitted to the facility on [DATE] and continues to reside in the facility. R1 has multiple diagnoses including, but not limited to the following: right femur fracture, muscle weakness, unsteadiness on feet, subdural hemorrhage, HTN (Hypertension), CHF (Congestive Heart Failure), CKD III (Chronic Kidney Disease stage 3), AFib (Atrial Fibrillation), gout, vascular dementia, right clavicle fracture, history of falling, depression, and CAD (Coronary Artery Disease). Facility incident report, dated 3/11/23 at 4:20AM, states in part but not limited to the following: CNA heard bed alarm and went to check on (R1). Noted patient lying on the floor on his left side by the footboard of the bed. Patient does not remember and states, I was dreaming that I was walking. Patient complains of slight pain to right shoulder. X-ray was ordered to right shoulder and urinalysis. Patient is alert and oriented x 1-2, forgetful and confused. New interventions: evaluate medications with MD and pharmacy input, neuropsychological evaluation, and check patient frequently. Facility care plan, with initiation date of 2/16/2023, states in part but not limited to the following: Focus: R1 is at risk for falls r/t generalized weakness secondary to right hip fracture status post ORIF (open reduction and internal fixation). Goal: Will remain free of falls through next review. Interventions: Ensure that the bed is in the appropriate lowest position for the patient and that the bed is locked as appropriate, dated initiated: 2/16/23; use of personal or pressure sensor alarms when in chair or bed, date initiated: 3/4/23; patient was reeducated on using his call light for assistance, date initiated: 3/4/23; evaluate medications with MD and pharmacy input, date initiated: 3/11/23; move resident to a room with optimal visual access from the nurses station, date initiated: 3/11/23, neuropsychological evaluation, date initiated: 3/11/23, check patient every 15 minutes, date initiated: 3/11/23; staff will do frequent checks on the patient, date initiated 3/11/23. On 05/04/23 at 11:20AM, V3 (Registered Nurse) was interviewed regarding R1. V3 said, (R3) is confused and he is a high fall risk. He needs increased supervision. On 05/05/23 at 10:05AM, V4 (Licensed Practical Nurse) was interviewed regarding R1's fall incident on 3/11/23. V4 said =he came to the facility due to a fall in which he fractured his hip. V4 said, I was the nurse on duty when (R1) fell on [DATE]. We found him lying on the floor by his footboard around 4:00AM. His bed alarm was going off which alerted us to his room, however, he was already on the ground. He was complaining of pain to his shoulder, so the doctor ordered an x-ray that morning. The x-ray showed him to have a fracture to his right clavicle. V4 said, (R1) is confused and forgetful and has been since admission. He does not often use his call light, and will attempt to get up on his own without calling for assistance. His room was moved closer to the nursing station after this fall to provide increased supervision. He is definitely high fall risk since he is unsteady and will get up without calling for assistance. Sometimes, I will be told that the resident is alert, but (R1) is not. It changes depending on the time of day. At 11:25AM, V6 (family member) was interviewed regarding care at the facility. V6 said her biggest concern with the facility is she feels as if they do not have enough CNAs (certified nursing assistants) and cannot provide adequate supervision, especially at night. Sometimes the call light time is really high and he (R1) has to wait a long time for assistance. (R1) gets confused at night time and tends to get up without assistance. (R1) had a fall prior to admission and came here for therapy. He was unsteady and a high fall risk even before admitting here. At 12:10 PM, V2 (Director of Nursing) was interviewed regarding R1's care and his fall incidents. V2 said R1 has had three falls while a resident here; 3/4/23, 3/11/23, and 3/29/23. V2 said, On 3/4/23, the intervention we put in place was re-education on using the call light to request assistance, adding the bed alarm, and increased supervision. Increased supervision means the staff will check on him every 15 minutes. On 3/11/23 R1 fell and sustained an injury. The interventions after 3/11/23 are we had the pharmacist review his medication and ordered a consult with a neuropsychologist. The pharmacist and neuropsychologist did not have any concerns. However, at this time they did diagnose him with dementia. This is the first time he was tested for dementia, but I believe it is not a new diagnoses. After this fall, we also moved him closer to the nursing station and we are ensuring his bed is in the lowest position. His bed was not in the lowest position when he fell on [DATE]. V2 said, After the first fall on 3/4/23, we recognized his pattern of constantly getting up without asking for assistance. (R1's) wife comes every day, spends most of the day here, and helps provide supervision. At night time, there is less people. It is to be noted that all three fall incidents occurred at night time, and R1 was attempting to get up without assistance or supervision. Facility policy titled Management of Falls, dated 08/2020 states in part but not limited to the following: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure: 3. Develop a plan of care to include goals and interventions which address resident's risk factors. 7. Monitor for changes in medical condition and notify physician as necessary to manage changes in status of the resident.

Based on observation, interview, and record review, the facility failed to follow physician orders to ensure resident received oxygen as prescribed, and failed to properly store oxygen tubing for 1 resident [R9] of 3 [R15, R272] residents in the sample of 12 residents. Findings include, R9's medical record documents in part: admitted on [DATE], with the medical diagnosis of chronic obstructive pulmonary disease, hypertensive heart disease syncope and collapse, atrial fibrillation, and congestive heart failure. Minimum data set brief interview for mental status score = 15 indicates R9 is cognitively intact. Physician order, dated 2/3/2023, respiratory oxygen per nasal cannula at 1 to 2 liters per minute continuous titrate to oxygen level is greater than 92% every shift. Care plan, dated 2/3/23, documents R9 requires oxygen therapy related to chronic obstructive pulmonary disease; intervention-Administer oxygen per MD orders. On 02/14/23 at 9:27 AM, R9 stated, I usually have on my oxygen, I don't know how long it has been off, I would guess it has been over an hour or more, because I'm finished with breakfast. I did not put the oxygen tubing on the couch. I've been in the bed all morning, and I cannot reach the couch from my bed. On 2/14/23 at 9:35 AM, surveyor and V4 [Registered Nurse] entered R9's room and observed R9's nasal cannula tubing lying directly on the seat of the couch. V4 stated, I'm not sure who placed (R9's) nasal canula on the couch instead of plastic bag. I don't see a plastic bag for (R9's) nasal cannula; I will go get another nasal canula and plastic bag for storage. The nasal canula lying on the seat of the couch could cause an infection. (R9) is fine; she does not receive oxygen all the time only as needed. On 2/14/23 at 1:34 PM, V4 stated, (R9) does have an order for continuous oxygen. I noticed on the shift report the physician assistant told the nursing staff to start weaning (R9) off oxygen. The nurses are responsible to remove the oxygen then record the oxygen saturation. I did not remove (R9's) oxygen, and I'm not sure who did or how long the oxygen was off. I do not see a physician order to wean (R9) off oxygen; the nurse did not place the order in. Typically, when I get information in report, I follow the plan. I did not check to see if there was a physician order. I was not the nurse who removed (R9's) oxygen today, and I am not sure who removed (R9's) oxygen or how long the oxygen was not on (R9). On 2/16/23 at 11:20 AM, V2 [Director of Nursing] stated, I been working here for [AGE] years as a floor nurse, but I been the Director of nursing here for 6 months. I completed one to one in-service with V4 [Registered Nurse] regarding once she receives a verbal order from the physician assistant, to get the order approved by the primary care physician and enter the order on the resident's electronic medication administration record. I also in-serviced all other nurses regarding physician orders. If a resident's oxygen is removed from their airway and not being monitored, the resident could have respiratory distress or shortness of breath. I also completed one to one in-service with V4 [Registered Nurse] regarding infection control, that oxygen nasal cannula tubing needs to be stored in a plastic bag when it is not in use to prevent infection. I also in-serviced all other nursing staff regarding infection control. If the resident oxygen tubing is not kept in a plastic bag, it could potentially cause an infection. On 2/16/23 at 1:45 PM, V1[Administrator] stated, The facility does not have a policy on oxygen tubing storage. Policy documented in part; Physician's Orders for Medication or Treatments -Medications will be dispensed and subsequently administered to a resident only upon the clear, complete, signed order of a lawfully authorized prescriber. -Verbal orders will be received only by licensed nurses or pharmacists and subsequently confirmed in writing by the prescribing physician. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order Policy: Documents in part: -Infection Prevention and Control Program The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on interview and record review, the facility failed to follow their practice to monitor and visually check the skin during heat therapy treatment, and failed to apply appropriate layers of toweling/padding to prevent an avoidable burn incident for 1 of 3 residents (R1) reviewed for safety and monitoring during heat therapy. This failure resulted in R1 developing blisters, swelling and redness to the right upper arm. R1 was assessed prescribed Silverdine 1% to applied to treat 2nd degree burn to the right upper arm. Findings include: R1's face sheet shows R1 is a [AGE] year old female with diagnosis of diabetes mellitus, muscle weakness, muscle wasting and atrophy. R1's Minimum Data Set, date 11/26/21, section C, shows, in-part, R1 has a BIMS score of 15 (cognitively intact). R1 Physician Order Sheet, dated 11/20/21, shows OT: pain management modalities as needed. Facility incident report, dated 12/9/21, completed by V5( nurse), shows, patient (R1) called author to room to assess her right arm. Patient states she feels slight pain/discomfort to her right arm, states she had requested a heat pack earlier to the CPT therapist and CPT therapist applied heat pack to her right arm with layered towels between skin and heat pack. Noted slight redness to her Right upper arm in a small area. Noted what appears to be a few popped blisters small in size 0.1 x 0.1cm with no drainage/no odor. Patient description, patient called author to room and states 'I'm not sure if there's anything on my arm, but it started hurting a little bit so I wanted you to look at it. The therapist had a heat pack on my arm with towels on it.' Action taken, Physician Assistant made aware with orders to cleanse site with NSS (normal saline), apply [MEDICATION(S)] Cream BID, cover with dry dressing, until healed. Patient made aware and is amenable for orders, will continue to monitor site. Patient at this time states she does not want author to inform family as she is alert and advocates for herself. Patient alert oriented x3. Nurse Practitioner made aware and will see patient for wound consult. Pain level is 1, Resident was not taken to the hospital, and resident is orient to place, time, person, and situation. Notes show per interview with the therapist (V2), R1 requested a heat pack for her arm. V2 stated she checked the temperature of the heating unit, wrapped the heat pack in a cover and towel, and placed the heat pack over R1 shirt. V2 stated she asked R1 multiple times if the heat pack was comfortable temperature on her arm, which R1 responded by telling her everything felt fine. V2 had returned R1 to her room. V5 is not available for interview. R1 wound assessments, dated 12/10/21, shows, in part, chief complaint patient seen consulted on the request of PCP( primary care physician) , for skin ulcers/[CONDITION(S)], pertinent diagnosis; deconditioning, weakness. R (right) upper arm superficial burn from the hot pack, R upper arm (lateral), a/o/2 in no apparent distress. Wound #1 R upper arm (lateral), exudate is light. Infection of inflammation is none. Seen with treatment nurse. Current medications reviewed for patient. Review of system, patient is overall stable, constitutional has fatigue, eyes no excessive tearing, eye pain, new visual changes, ENT and mouth. Denies nose bleed, dysphagia, ear pain, ear discharge, respiratory no cough, SOB (short of breath) wheezing, hemoptysis, CVS, denies chest pain, palpitation, swelling. Incontinence, muscle skeletal- has joint stiffness/weakness, difficulty in walking deconditioning, neurological weakness and poor balance, numbness tingling, tremors, headache, has allergies see allergy list. Integumentary has skin wound/[CONDITION(S)] per wound sheet. Vitals BP 122/72, temp 98.7, pulse 72, weight 219LBS( pounds) , resp 17, BS 183, O2( oxygen) 97%, pain 0. Physical exam skin wound and skin lesion at wound #1- R upper arm (lateral). Constitutional - appears clean in no apparent distress, has generalized weakness. Built is fair, eyes conjunctive clear no drainage, GI incontinence, respiratory breathing comfortably, psychiatry and neurology A/o, affect-calm, cooperative on examination. Wound related exam 12/10/21 MSK functional status with chair dependent, contracture stiff. Right foot pulse ¼ capillary refill-seconds, left foot pulse ¼ capillary refill-seconds. Motor- weakness of limbs- yes. Assessment and Plan, wound related diagnosis, Burn of second degree of right upper arm, initial encounter, R upper arm (lateral), frequency of treatment daily and PRN( as needed), site should be clean with normal saline, primary dressing- [MEDICATION(S)], secondary dressing-4x4, secure with dry dressing, medical necessity, multiple problems and multiple risk factors, deconditioned, above multiple medical conditions can cause worsening of wounds, development of new wounds and delayed wound healing and infection. Therefore patient needs to be seen every week. Today's management: skin and wound was examined and plan of care was discussed with the wound team and charted. Goals- for skin ulcers, wound healing, prevention of infection, wound related pain management, prevention of further development of new ulcers. Wound assessment: wound number 1 , not resolved, R upper arm, date reported 12/10/21, size in Cm ( LxWxD) 2x1x0.1 , volume based on area- 0.2, area based on LxW- 2, other tissue- 100% multiple open blisters, light exudate, no odor, no infection. Treatment done/ recommended on 12/10/21, date treatment initiated12/10/21, treatment for 30 days, daily and PRN (as needed) clean with normal saline, apply topical [MEDICATION(S)], cover with 4x4, anchorage- dry dressing. Electronically signed by V4 (Wound Physician) on 12/10/21. R1 progress note, dated 12/09/21, patient called author(V5) to room to assess her right arm. Patient states she feels slight pain/discomfort to her right arm, states she had requested a heat pack earlier to the CPT therapist and CPT therapist applied heat pack to her right arm with layered towels between skin and heat pack. Noted slight redness to her Right upper arm in a small area. Noted what appears to be a few popped blisters small in size 0.1 x 0.1cm with no drainage/no odor. Physician Assistant made aware with orders to cleanse site with NSS, apply [MEDICATION(S)] Cream BID (twice a day), cover with dry dressing, until healed. Patient made aware and is amenable for orders, will continue to monitor site. Patient at this time states she does not want author to inform family as she is alert and advocates for herself. Patient alert oriented x3. Review of R1's TAR (Treatment Administration Record) shows R1 received treatment of [MEDICATION(S)] cream 1% ( sliver silfadiazine) to right upper arm topically two times a day for skin condition, cleanse with normal saline, apply dry dressing until healed from 12/10/21 to 12/19/21. On 12/29/21 at 11:40am, R1 was observed to be sitting in R1's room doing upper arm exercises. R1 gave permission for entry to R1's room. R1 was observed to be alert and orient to person, place, time, and situation. R1 said during a therapy session on 12/09/21, R1 received a heat pack, and shortly after therapy, R1 was experiencing some discomfort, and R1 summoned the nurse, and asked the nurse to take a look. During that assessment, R1 had a few blisters on R1's arm. R1 said they are now healed. R1 raised the sleeve of R1's shirt to allow for observation. R1's skin was observed to be intact; 3 faint pink spots were observed where R1 pointed. R1 said R1 requested the heat pack as R1's usual from V2 (Occupational Therapy assistant). R1 said the hot pack was in the cloth pouch ([NAME] cloth), and then V2 wrapped a towel around the pouch and placed it on R1's right upper arm. On 12/29/21 at 12:07pm, V2 (Occupational Therapy Assistant) said V2 was working with R1 on 12/9/21. V2 said during the upper body strengthening exercise, R1 requested a heat pack, and V2 applied the heat pack to R1's right upper extremity. V2 said V2 wrapped the hot pack in the [NAME] cloth, and then double folded a large towel and placed the hot pack to R1's right shoulder area, and the hot pack rested on the upper arm (hot pack on top). V2 said the double folded towel and the [NAME] cloth is considered 6 layers. V2 added R1 had a shirt on, but it wasn't considered another layer of protection. V2 said V2 asked R1 several times how does it feel and R1 said okay. V2 said V2 did not check R1's skin before a applying the heat therapy, V2 did not check R1 skin during the heat therapy treatment, and V2 did not check R1's skin after the heat therapy treatment. V2 said it was toward the end of the session, and R1 only had the heat pack on for about 8 minutes. V2 said after occupational therapy services, V2 escorted R1 back to R1's room. V2 said V2 was supposed to check R1 arm prior to, during and after the heat therapy. On 12/29/21 at 11:52am, V3 (Therapy Supervisor) said heat therapy application can last up to 15 minutes, depending on how the resident feels. During an observation of the heating unit, the water temp was observed to be at 158 degrees Fahrenheit. V3 said the water temperature can get as high as 162 degrees Fahrenheit. V3 said there should be 6 to 8 layers of protection between the resident's skin and the heat packs. V3 said the use of 6 to 8 layers of towels depends on how the resident feels. V3 said each side of the [NAME] cloth is considered 2 layers, a folded towel is considered one layer, and a double folded towel is considered 2 layers. V3 present temperature log (temp range noted to be 162 degrees Fahrenheit) for heating unit and a document titled thermal therapy. On 12/30/21 at 10:24am, V3 (Therapy supervisor) said V3 does not know when the time should start for the heat therapy application. V3 does not know if it's when the patient starts feeling the treatment (heat), or when the application is applied. V3 said the resident's skin should be checked before applying the heat therapy for irritation and anything abnormal, and after applying the heat therapy for blisters, more redness than usual (because there will be some light redness from use), irritation to the skin, [CONDITION(S)], and anything abnormal. When asked do you visually check the skin during treatment, V3 said the skin is checked during treatment by asking the resident do you feel heat, and this is done periodically. V3 said V3 does not have a time frame for periodically checking the skin during heat therapy. On 12/30/21 at 12:00pm, V1 (Director of Nursing) said it is V1's expectation there is a visual assessment of the resident skin during a heat therapy treatment for redness or any reactions to the treatment. V1 said residents should also be asked is the treatment comfortable, is it too hot, is it too warm and is there any discomfort. V1 said the facility does not have a policy on use of thermal therapy, but the therapist has guidelines they follow. V1 said V1 expects the therapist follow their guidelines when using the thermal therapy. V1 said R1 sustained a superficial burn to the right arm and was treated with cream. V1 said V1 can't say what the frequency for periodically checking the skin during heat therapy. V1 said R1 was seen by the wound doctor on 12/10/21. Facility in-service/ meeting attendance record, dated 12/9/2021, shows, in part, topic- proper layers for hot packs (6 to 8 layers) and cold packs. Proper layers for hot pack/cold packs. Demonstration and therapist demonstration, checking skin site before and after treatment. Towel equal 1 layer, folded towel equal 2 layers, hot pack cover equal 2 layers. Review of the in-service document does not show in-service education on periodically visually checking the skin during the thermal therapy; it does not show education on asking the resident about discomfort, asking if the heat therapy is too hot, or too warm. Facility policy Titled Accidents/ Incident Reports, dated 09/2020, shows, in part, Procedure- an accident refers to the unexpected or unintentional incident, which may result in injury or illness to a resident. This does not include adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current standards of practice (i.e drug side effects or reaction). The Thermal Therapy Guideline document, with no date noted, shows, in part, must obtain a MD ( Medical Doctor) order in order to use these modalities, hot moist pack, definition: moist heat applied by means of a preheated chemical pack of silica get insulated in six to eight layers of toweling. Temperature: 160 degrees Fahrenheit to 165 degrees Fahrenheit, or defer to manufacture for temp range; temperature checks need to be recorded daily. Normal treatment time 15 minutes with periodic checks. Effects/Indications; relief of pain, increase blood flow, relaxation of muscle spasm. Precautions: special care must be taken with thin, aged persons and children, avoid chilling and burning. Take care not to burn unconscious , paralyzed, diabetic, edematous patients or patient with impaired local circulation, do not apply where the is danger of hemorrhage, do not apply where there is suspected malignancy unless physician orders for palliative care measures, do not spread infection, always have covering between patient skin and pack for sanitary reasons, remove all clothing and inspect skin before and after application, use intensity of heat as indicated by the patient condition, comfort, and the effect to obtain, protect sensitive spots and bony prominences, packs should be check periodically for hot spots or burning. Contraindications: acute DVT, absent temperature sensation.

Based on record review and interview, the facility failed to follow physician order [REDACTED]. Findings include : R3 was admitted to the facility on ,[DATE] 10 with [DIAGNOSES REDACTED]. Per Physician order [REDACTED]. Review of R3's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E6 indicated at the back of R3's MAR indicated [REDACTED]. Review of R3's nurses notes showed that Z1 was not made aware that R3's [MEDICATION NAME] was withheld because of diarrhea until 4/5/10. When Z1 was interviewed over the phone on 8/27/10 at 3:29 PM, Z1 said that even though R3 had diarrhea, R3 should still be given her [MEDICATION NAME] for her hepatic [MEDICAL CONDITION]. Z1 added that there isn't much that could be prescribe for R3 for her Hepatic [MEDICAL CONDITION] aside from [MEDICATION NAME] and Rifaximin which R3 was already getting from the facility.